The Lev at Winchester

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for 1 of 9 residents (Resident #1) reviewed for participating in care planning. The facility did not conduct a meeting nor invite Resident #1 to participate in resident care planning meetings after his quarterly review assessments on 5/23/25, 8/22/25 and 10/29/25. This failure could place residents at risk for a loss of independence, psychosocial well-being and the opportunity for them to participate in the planning of their care. Findings Included: Record review of Resident #1's admission record generated on 12/5/25 revealed she was admitted to the facility on [DATE] and had diagnoses of mental disorder (characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior), vascular dementia (a decline in thinking skills due to reduced blood flow to the brain, often from strokes or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 5 months (January, February, April, and May of 2025) reviewed for nursing services. The facility failed to ensure a registered nurse worked on 1 day out of 31 days in January of 2025.The facility failed to ensure a registered nurse worked on 3 days out of 28 days in February of 2025 The facility failed to ensure a registered nurse worked on 1 day out of 30 days in April 2025.The facility failed to ensure that a registered nurse worked 2 days out of 31 days in May of 2025 These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.Findings included: Record review of the CMS PBJ Staffing Data Report for FY Quarter 2 2025 (January 1- March 31) with run date 07/28/2025 revealed, the facility was triggered for four or more days within the quarter for no RN hours on the following days in 2025:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #58) of 7 residents reviewed for quality of care. -Resident #58 developed a sacral (bone at the base of the spine and the surrounding area) wound on 08/01/25 and the facility did not get physician orders to treat the sacral wound until 08/05/25. This failure placed resident at risk for further skin breakdown to the sacral wound, infections, and pain.Findings: Record review of Resident #58's face sheet dated 08/05/26 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included right fracture femur (thigh bone), dementia (brain disorder that causes problems with thinking, memory, and behavior), depression, and fibromyalgia (pain, fatigue, sleep problems, mood issues, and difficulty concentrating).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish, maintain and implement identical policies and practices regarding transfer and discharge and the provision of services for all individuals regardless of source of payment for 1 (Resident #5) of 4 residents reviewed for equal access to quality care. The facility failed to ensure Resident #5's right to stay in the facility and he was transferred to the hospital because his payor source ended. The failure could place residents at risk of a loss of self-determination and dignity.Findings included: Record review of Resident #5's face sheet dated 8/6/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included synovitis and tenosynovitis (painful inflammatory conditions affecting the joints and tendons) of the left ankle and foot, idiopathic aseptic necrosis (the death of bone tissue due to a lack of blood supply) of left ankle, acute kidney failure, morbid obesity, Type 2 Diabetes Mellitus (glucose levels in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident#27 and Resident #31) of 14 residents reviewed for accuracy of assessments. The facility failed to ensure Resident#27's significant change MDS assessment dated [DATE] accurately reflected her lack of natural teeth in her oral cavity. The facility failed to ensure Resident #31's comprehensive MDS assessment dated [DATE] accurately reflected her decaying and lack of natural teeth in her oral cavity. This failure could place residents at risk for receiving inadequate care and services due to inaccurate assessments. The findings included: Record review of Resident #27's face sheet dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Dementia, history of falling, major depressive disorders, lack of coordination, generalized anxiety, psychotic disturbance, and mood disturbance. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (Resident #65) of 7 residents reviewed for infection control.-LVN F was carrying soiled linen in hand from Resident #65's room up the hallway and placed it inside of the soiled barrel on the hallway. This failure placed residents, staff members, and visitors at risk for cross contamination and infections. Findings:Record review of Resident #65's face sheet dated 08/06/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 07/14/25. Resident diagnoses included heart failure, hypertension (high blood pressure), chronic kidney disease, neuromuscular dysfunction of the bladder (nerve damage that impairs the bladder's ability to store and release urine properly), type 2 diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws,all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 nurse medication carts reviewed for medications . 1. The facility failed to ensure 2 of 3 nurses' medication carts did not contain expired oral medications. 2. The facility failed to ensure 1 of 3 nurse's medication carts did not contain expired suppository medication. These failures could place residents at risk for altered effectiveness of the medication and decreased therapeutic outcomes, requiring medical intervention. The findings include: During an observation on 06/27/24 at 1:58 p.m. of medication cart 1 of 3 with LVN A revealed the following: a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and expired on 12/27/23. a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and expired on 05/03/24. a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week for 1 out of 30 days reviewed June 2024. The facility failed to ensure RN coverage for Sunday, 06/02/2024 . This failure could place residents at risk for not having adequate qualified personnel in case of a health crisis. Findings include: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 2, 2024, run date 06/02/2024, reflected Low Weekend Staffing was triggered (Submitted Weekend Staffing data is excessively low). Record review of the monthly staffing schedule dated June 2024, reflected no RN coverage on 06/02/2024 . During an interview on 6/28/2024 at 1:17 PM, the DON said when she filled in for staff, she would usually sign the bottom of the Staffing Daily Posting. She said the Staff Daily Posting did not show her signature dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #8) of 2 resident reviewed for respiratory care, in that: -The facility failed to set the oxygen flow rate at 3 liters of oxygen per minute as ordered on 11/27/2023 for Resident #8. This deficient practice could place residents at risk of inadequate respiratory support or respiratory infections resulting in a decline in health. Findings included: Record review of Resident #8's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8's diagnoses included chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe) and dementia (A group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #8's Comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed ensure, except when waived, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. -The facility failed to ensure there was RN (Registered nurse) coverage on 1/8/23, 1/14/23, 1/21/23, 1/22/23, 2/4/23, 2/5/23, 2/26/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/25/23, and 03/26/23. This failure could place residents at risk of not having their nursing and medical needs met. Findings Included: During an interview with the DON on 04/06/2023 at 10:05 AM, she stated she normally worked Monday- Friday, 8AM-5PM. She stated she works during the week and when available she works on the weekends. She stated the facility recently hired two RNs for the weekends. She stated for about 2 months, she was the only RN working at the facility. She stated during the times she was not physically at the facility; she was available by phone. She stated she signed a shift sign-in sheet on the days she was able to work on the weekends. She stated she did not really think there was a risk of her not being physically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service safety, in that: The failure could place residents at risk of foodborne illness. -Staff personal items were stored with resident's food. -Items were not dated Findings include: Observation of the kitchen on 04/05/2022 at 8:15 AM, revealed 20 oz Coca Cola bottle of soda half empty in the refrigerator, no name or date, 1 can of Monster Energy Drink and 2 can sodas of Dr. Pepper in the refrigerator. During an interview on 04/05/2023 at 10:51AM with the Dietary Manager, he stated he had been employed at the facility for about 2 weeks. He stated the staff was to place their personal items in their lockers and stated they should not have their items placed with residents' items. He stated he will let the staff put their lunch in the refrigerator with the residents food, but if it was there longer than 30 minutes, he would throw the items away. He stated all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 resident observed for blood glucose monitor for (Resident #42) and 1 of 1 resident observed for feeding assistance (Resident #28). 1. LVN D failed to properly change gloves and wash or sanitize hands after providing blood glucose monitor to Resident #42. 2. CNA B failed to properly wash or sanitize her hands after scratching her head while providing feeding assistance to Resident #28. This deficient practice placed 1 of 1 resident who received frequent blood glucose monitoring and 1 of 1 resident require feeding assistance at risk for cross contamination and/or spread of infection. Findings include: Review of the Facesheet dated 04/06/23 revealed Resident #42 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus with Diabetic Neuropathy, Bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #27) reviewed for indwelling catheter care. 1. Resident #27's indwelling catheter bag was undated. 2. Resident #27's electronic data chart had not record of indwelling catheter's last change or placement date. This deficient practice placed 2 residents who require indwelling catheter care and 86 residents who require electronic data charting at risk for errors in care and treatment. Findings include: Record Review Face Sheet dated 04/06/23 revealed Resident #27 is a [AGE] year-old male admitted to the facility on [DATE]'s diagnosis was Sepsis, Unspecified Organism, Personal History of Urinary Calculi, Neuromuscular Dysfunction of Bladder, Unspecified, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Record Review Resident #27's Care Plan last updated 04/03/23 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to document if the resident received the pneumococcal immunization, Covid-19 vaccination, or the Mantoux tuberculin skin test due to medical contraindication or refusal for 1 of 9 residents (#83) whose medical records were reviewed for immunizations: 1. Resident #83's medical record had no immunization records being administered or refused. This deficient practice could affect 86 residents who were admitted since April 2021 and put them at risk for infection. The findings were: Record review of Resident #83's Face Sheet revealed an admission date of 01/23/2023 with diagnoses of Spondylosis, Wedge Compression Fracture of First Thoracic Vertebra, Initial Encounter for Closed Fracture, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Obesity. Record review of Resident #83's most recent Care Plan revealed resident was at risk for infection related to Covid-19, will be offered flu/pneumonia vaccine per protocol. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.